Food craving frequency mediates the relationship between emotional eating and excess weight gain in pregnancy

Eating Behaviors 31 (2018) 120–124

Contents lists available at ScienceDirect

Eating Behaviors journal homepage: www.elsevier.com/locate/eatbeh

Food craving frequency mediates the relationship between emotional eating and excess weight gain in pregnancy

T

⁎

Lauren E. Blaua, , Natalia C. Orloffa, Amy Flammerb, Carolyn Slatchb, Julia M. Hormesa,b a b

University at Albany, State University of New York, United States of America Albany Medical College, United States of America

A R T I C LE I N FO

A B S T R A C T

Keywords: Craving Emotional eating Pregnancy Gestational weight gain

An estimated 50% of pregnancies in the U.S. are associated with maternal weight gain that exceeds Institute of Medicine recommendations. The numerous adverse consequences of obesity in gestation, delivery and the postpartum have been widely documented. The role of excess gestational weight gain (GWG) as a predictor of lifetime obesity risk in mothers and their children is also increasingly recognized. Cravings and negative affect are commonly cited triggers of overconsumption in pregnant women. We sought to examine the role of food craving frequency as a mediator in the relation between emotional eating and excess GWG. In this cross-sectional study, pregnant women (n = 113) completed the Dutch Eating Behavior Questionnaire, a measure of “restrained,” “emotional,” and “external” eating styles, along with the Food Craving Inventory, which quantifies cravings for “high fat foods,” “fast food fats,” “carbohydrates/starches,” and “sweets.” Participants also reported on pre-pregnancy weight and height, and GWG at the time of survey completion. Data supported the hypothesized mediation model, with frequency of “high fat foods” cravings fully mediating the relationship between “emotional” eating and excess GWG (Sobel test z = 2.40, p = .016). This study addresses the striking dearth of research examining potentially modifiable psychosocial predictors of excess GWG. Future longitudinal research should examine if salient affective states trigger food cravings, thus placing pregnant women at increased risk of excess weight gain. Findings have implications for treatment interventions targeting excess GWG, suggesting a need to teach skills to help patients better manage low moods and cravings.

Gestational weight gain (GWG) has important health outcomes for both the mother and the child. Recent research has estimated the prevalence of excess gestational weight gain in the United States ranges from 38 to 54%, depending on the state (Deputy, Sharma, & Kim, 2015). According to Institute of Medicine (IOM) recommendations, pregnant women should gain weight based on their pre-pregnancy body mass index (BMI) as follows: 28–40 lbs for BMI in the “underweight” range (< 18.5); 25–35 lbs for normal weight women (18.5–24.9); 15–25 lbs for women with pre-pregnancy overweight (25.0–29.9); and 11–20 lbs for women with pre-pregnancy obesity (≥30.0) (Rasmussen & Yaktine, 2009). Weight gain is expected to be minimal in the first trimester, with recommended average weekly weight gain in the second and third trimesters ranging from about 0.65 to 1.0 pounds depending on pre-pregnancy BMI. Accordingly, guidelines recommend that caloric intake increase over the course of pregnancy, with no additional calories (i.e., above recommended pre-pregnancy daily intake) to be consumed during the first trimester, and a recommended increase of about 340 and 450 additional calories per day during the second and

⁎

third trimesters, respectively (Wolfram, 2017). Excess GWG is associated with an elevated risk of a number of physical and psychological problems including, but not limited to, gestational diabetes mellitus, hypertension, preeclampsia, premature birth, body dissatisfaction, and failure to initiate breastfeeding (ADA, 2002; Galtier-Dereure, Boegner, & Bringer, 2000; Hilson, Rasmussen, & Kjolhede, 1997; Rasmussen & Yaktine, 2009; Stotland, Hopkins, & Caughey, 2004; Thorsdottir, Torfadottir, Birgisdottir, & Geirsson, 2002; Vahratian, Siega-Riz, Savitz, & Zhang, 2005). Excess weight is currently among the most common and costly high-risk obstetric conditions, with evidence suggesting an increased risk of cesarean deliveries and postoperative complications in mothers who gain in excess of these formal guidelines for GWG (Galtier-Dereure et al., 2000; Stotland et al., 2004). Excess GWG can also be detrimental to the health of the newborn child and has been identified as a strong predictor of macrosomia, large for gestational age neonates, and low Apgar scores (Gante, Amaral, Dores, & Almeida, 2015). In addition to this host of immediate adverse consequences, excess

Corresponding author. E-mail address: [email protected] (L.E. Blau).

https://doi.org/10.1016/j.eatbeh.2018.09.004 Received 27 February 2018; Received in revised form 20 August 2018; Accepted 14 September 2018 Available online 20 September 2018 1471-0153/ © 2018 Elsevier Ltd. All rights reserved.

Eating Behaviors 31 (2018) 120–124

L.E. Blau et al.

example, both general and pregnancy-related stress are associated with unhealthy eating habits and emotional eating (i.e., eating in response to internal, affective states) during gestation (Chang, Nitzke, Guilford, Adair, & Hazard, 2008; Lobel et al., 2008). Worry over weight gain was found to be associated with higher GWG and greater likelihood of high infant weight (Swann et al., 2009). To the best of our knowledge, the predictions of EI Theory have not yet been tested empirically in pregnant women. Three types of eating patterns or “styles” – quantified by the widely used and well-validated Dutch Eating Behavior Questionnaire - have emerged as significantly related to weight gain in the general population: external (eating in response to an external food cue), emotional (eating in response to an emotion or mood state), and restrained (restrictive eating) (Burton et al., 2007; Van Strien, Frijters, Bergers, & Defares, 1986). This study was designed to examine the relationships between these specific eating styles, food cravings, and excess weight gain in pregnancy, with the goal of laying the foundation for future research to identify suitable targets for promoting healthy gestational weight. Based on prior findings, and consistent with the predictions of EI Theory, we hypothesized that craving frequency mediates the relationship between emotional and external eating styles and excess GWG.

GWG is predictive of obesity risk across the lifespan. It increases the likelihood of maternal postpartum weight retention and obesity later in life (Mamun et al., 2010; Siega-Riz et al., 2009). Pre-pregnancy maternal weight and GWG are also associated with increased offspring body mass index (BMI) at three years of age (Oken, Taveras, Kleinman, Rich-Edwards, & Gillman, 2007; Stamnes Koepp et al., 2012). This impact has been shown to continue into adolescence (Laitinen et al., 2012; Oken, Rifas-Shiman, Field, Frazier, & Gillman, 2010), increasing the likelihood of cardiovascular disease and adverse metabolic health outcomes throughout the offspring's lifetime (Gaillard, 2015). There has been a proliferation of studies documenting the adverse consequences of excess GWG in recent years. However, there remains a relative dearth of research specifically designed to identify risk factors for excess GWG that could serve as targets for more effective prevention and treatment interventions. Numerous published studies test the efficacy of interventions targeting diet and physical activity as a means of promoting healthy gestational weight gain (Hill, Skouteris, FullerTyszkiewicz, & McPhie, 2016; Liu, Wilcox, Whitaker, Blake, & Addy, 2015; McGiveron et al., 2015; Olson, Strawderman, & Reed, 2004; Polley, Wing, & Sims, 2002; Skouteris et al., 2010). Unfortunately, systematic reviews suggest that these studies demonstrate, at best, small effects only in specific BMI subgroups of pregnant women (Skouteris et al., 2010). For example, the “Fit for Delivery” program, leading in the prevention of excess GWG, is effective in normal weight women, but has no significant impact on GWG in overweight or obese women (Phelan et al., 2011). There is thus a strong need for research to identify modifiable predictors of excess GWG that can be targeted by intervention efforts. As many as 70% of women experience cravings or strong, irresistible urges for specific foods at some point in pregnancy (Bayley, Dye, Jones, DeBono, & Hill, 2002b; Fairburn, Stein, & Jones, 1992; Flaxman & Sherman, 2000; Hormes & Rozin, 2010; Pope, Skinner, & Carruth, 1992), with cravings for “sweets” and “carbohydrates” being most commonly endorsed (Orloff & Hormes, 2014). Preliminary research suggests that food craving frequency increases markedly in the second trimester of gestation and drops off subsequently (Bayley, Dye, Jones, DeBono, & Hill, 2002a; Harries & Hughes, 1958; Pope et al., 1992). Early on in pregnancy, women tend to endorse cravings for savory substances (Belzer, Smulian, Lu, & Tepper, 2010), with urges for sweets reaching peak intensity during the second trimester (Bowen, 1992), and cravings for salty substances emerging later in pregnancy (Bowen, 1992; Crystal, Bowen, & Bernstein, 1999; Skinner, Pope, & Carruth, 1998). Food cravings are one of the most significant barriers to healthy eating in pregnant women (Goodrich, Cregger, Wilcox, & Liu, 2013), and craving frequency was previously found to account for as much as one third of the variance in excess weight gain in pregnancy (Orloff et al., 2016). There is little evidence to support a role of hormonal fluctuations, nutritional deficits or needs of the developing fetus, or pharmacologically active ingredients in the emergence of food cravings, including in pregnancy (Orloff & Hormes, 2014). Instead, cravings are now widely conceptualized as cognitively motivated states. For example, the Elaborated Intrusion (EI) Theory of Desire views cravings as a product of a two-step process: (1) external (e.g., the smell of a favorite treat) or internal (e.g., boredom or anxiety) cues trigger an automatic thought about the target of the craving and (2) the automatic thought is actively elaborated upon (e.g., thinking about the last time the craved food was consumed, picturing its appearance and texture, and making plans to obtain it in the future) (Kavanagh, Andrade, & May, 2005). Research in non-pregnant populations is consistent with EI Theory. For example, prior work suggests that food craving mediates the effect of external eating (i.e., eating in response to cues in the environment) on BMI (Burton, Smit, & Lightowler, 2007). In addition to cravings, pregnant women also commonly identify both emotional and social factors as influencing their eating behavior (Paterson, Hay-Smith, Treharne, Herbison, & Howarth, 2016). For

1. Method All methods were reviewed and approved by the local Institutional Review Board. Respondents were informed of the nature and purpose of the research and consented prior to the completion of questionnaires. 1.1. Participants and design Participants in this cross-sectional study were 113 pregnant women (mean age M = 30.70, SD = 4.65) recruited at a local academic medical center (54.9%, n = 62) and online (45.1%, n = 51). Participants self-identified as white (72.6%, n = 82), black/African-American (17.7%, n = 20), Asian (8.0%, n = 9), and Hispanic/Latino (6.2%, n = 7). Inclusion criteria included being 18 years or older, proficient in English, and enrolled in routine prenatal care. Online participants were recruited on social media sites and were not given any incentives for participation. Recruitment at the hospital was conducted as part of an ongoing longitudinal study of eating behaviors and psychological health of pregnant women and women were given gift cards upon completion of the survey. Average weeks of gestation at survey completion was 24.05 (SD = 8.84). Half of all respondents (49.1%, n = 54) were in the second trimester of pregnancy at the time of survey completion (M = 20.70 weeks of gestation, SD = 3.98), 39.1% (n = 43) were in the third trimester (M = 20.70, SD = 3.98 weeks of gestation), and 11.8% (n = 13) completed the questionnaire during the first trimester (M = 8.62 week of gestation, SD = 2.96). At the time of survey completion, almost half of participants reported pre-pregnancy BMI in the under- or normal weight range (i.e., BMI < 24.9, 46.1%, n = 47), 22.5% (n = 23) reported body mass in the overweight range (i.e., BMI 25.0–29.9), and 31.4% (n = 32) endorsed pre-pregnancy obesity (i.e., BMI > 30.0). There were no statistically significant differences in FCI craving “frequency” or frequency of “giving in” to cravings by trimester (p = .52, 0.74, respectively) or by pre-pregnancy BMI (p = .94, 0.62). We therefore combined all respondents in subsequent analyses. 1.2. Measures 1.2.1. Dutch Eating Behavior Questionnaire (DEBQ) The DEBQ is a 33-item self-report measure that quantifies “emotional” (Cronbach's α = 0.96 in the present sample), “external” (Cronbach's α = 0.88), and “restrained” (Cronbach's α = 0.91) eating styles (Van Strien et al., 1986). “Emotional” eating refers to excessive 121

Eating Behaviors 31 (2018) 120–124

L.E. Blau et al.

SD = 6.32) and second trimesters (M = −0.93, SD = 10.01), who on average reported weight gain below formal IOM guidelines for their stage of pregnancy [F (2, 96) = 4.34, p = .02, ηp2 = 0.08]. Excess GWG was significantly and positively correlated with “emotional” and “external,” but not “restrained” eating (Table 1), as well as with reported frequency of cravings for “high fat foods” and “fast food fats” (Table 2). Eating styles accounted for 11% of the variance in excess GWG, with “emotional” eating emerging as the single significant correlate in linear regression analysis (Table 1). Food craving frequency accounted for 22% of the variance in excess GWG, with frequency of cravings for “high fat foods” and “carbohydrates/ starches” emerging as significant correlates (Table 2). The total effect of “emotional” eating on excess GWG was significant (b = 0.24, SE = 0.11, p = .02, 95% C.I.: 0.03, 0.45), as was the regression of “emotional” eating on frequency of craving for “high fat foods” (b = 0.35, SE = 0.11, p = .002, 95% C.I.: 0.13, 0.57). Controlling for the hypothesized mediator, craving for “high fat foods,” “emotional” eating was no longer a significant correlate of excess GWG (b = 0.11, SE = 0.11, p = .295, 95% C.I.: −0.10, 0.32), suggesting full mediation (Fig. 1). A Sobel test was significant (z = 2.40, p = .02). The reverse mediation model (i.e., with frequency of craving for “high fat foods” as the independent variable and “emotional” eating as the mediator) was not significant. Given the lack of a significant correlation between frequency of cravings for “carbohydrates/starches” and excess GWG, its role as a possible mediator in the relationship between eating styles and weight gain in pregnancy was not assessed.

consumption in response to arousal states such as anger, fear, or anxiety. “External” eating is a reaction to food-related stimuli, regardless of the internal state of hunger and satiety. Finally, “restrained” eating is indicative of restrictive eating behavior, often due to dieting. The DEBQ is thus uniquely suited to testing the predictions of EI Theory, which postulates that responsiveness to external and internal (i.e., emotional) cues triggers the cognitive processes that cause and maintain craving episodes. To our knowledge, the DEBQ has not been formally validated in pregnant populations; however, it has previously been used to quantify eating styles in pregnant women (Shloim, Hetherington, Rudolf, & Feltbower, 2015). 1.2.2. Food Craving Inventory (FCI) The FCI measures frequency of cravings for 28 different foods in the past month. Ratings range from 1 = “never” to 5 = “always/almost every day” and load onto four factors, assessing frequency of craving for “high fat foods” (Cronbach's α = 0.77 in the present sample), “sweets” (Cronbach's α = 0.83), “carbohydrates/starches” (Cronbach's α = 0.78), and “fast food fats” (Cronbach's α = 0.56), along with the frequency of giving in to cravings for “high fat foods” (Cronbach's α = 0.79), “sweets” (Cronbach's α = 0.76), “carbohydrates/starches” (Cronbach's α = 0.89), and “fast food fats” (Cronbach's α = 0.90). 1.2.3. Excess gestational weight gain Pre-pregnancy weight and weight at the time of survey completion was based on self-report measures, which has been shown to be largely concordant with actual measured weights (Bannon et al., 2017). Excess GWG at the time of survey completion was calculated based on prepregnancy BMI, stage of gestation at time of survey completion, and Institute of Medicine guidelines for “normal” weight gain versus “excess” weight gain in pregnancy (Orloff et al., 2016; Rasmussen & Yaktine, 2009).

3. Discussion The goal of this study was to examine the influence of specific eating styles and food cravings on excess GWG. Our data support the hypothesis that frequency of cravings for high fat foods acts as a mediator in the relationship between a tendency to eat in response to emotional cues and excess GWG. As such, findings are consistent with EI Theory, which postulates that internal and/or external cues act as proximal antecedents of craving episodes, which, in turn, increase consumption and weight. Whereas EI Theory predicts a role of both external and internal cues in triggering the automatic thoughts that are thought to be the initial cause of craving episodes, our results suggest internal, affective, as opposed to external cues, may be the most prominent craving triggers specifically in pregnancy. There are a number of important limitations to this work that must be noted. The cross-sectional nature of the data means that findings should not be interpreted as implying causality. They are, however, consistent with past longitudinal research showing that food craving mediates the relationship between eating styles and weight in nonpregnant respondents (Burton et al., 2007). Future research should test the hypothesized mediation model in a longitudinal design. Other methodological limitations include potential differences between respondents recruited online versus in-person. Furthermore, the factor structure of the FCI or DEBQ has not been formally replicated in pregnant samples. Future work should examine the psychometric properties of these measures in pregnant samples in order to determine their validity for use in research on eating behaviors in pregnancy. Lastly, women in this study were pregnant when they completed the survey, and therefore the total amount of their GWG is not known. However, the majority of women in this study were in their second and third trimesters and excess GWG was calculated taking into account their current stage of pregnancy and recommended weight gain for that stage. Animal research suggests that maternal consumption of a high-fat diet is associated with obesity in the offspring (Bain et al., 2015), possibly via epigenetic changes in pregnancy (Sanabria-Martinez et al., 2015). Furthermore, high-fat diets in pregnant women have been shown to negatively influence the infant's gut microbes, which can have significant effects in the development of the immune system and on

1.3. Statistical analyses Relationships between all variables were examined using Pearson's correlation coefficients r and linear regression analyses. All variables were standardized prior to regression analyses. A power analysis, conducted using G*Power, indicated a minimum sample size of 85 for adequate power (≥0.80) to detect a medium-sized effect in linear regression analysis with four predictors. Based on findings from preliminary analyses, we tested the role of frequency of craving for “high fat foods” as a mediator in the relationship between “emotional” eating style and excess GWG at the time of survey completion (see Fig. 1). The hypothesized mediation model was examined using the PROCESS macro for SPSS version 24 (“Model 4”) (Hayes, 2012, 2013). Indirect effects were subjected to follow-up bootstrap analyses with 10,000 bootstrap samples and 95% bias corrected confidence intervals (C.I.). 2. Results At the time of survey completion, 45.4% (n = 45) of respondents had gained in excess of the recommended GWG for their stage of gestation and pre-pregnancy BMI. Women in the third trimester were most likely to have gained in excess of recommended IOM GWG (M = 5.78, SD = 14.74), compared to women in the first (M = −2.73,

Fig. 1. Hypothesized mediation model. 122

Eating Behaviors 31 (2018) 120–124

L.E. Blau et al.

Table 1 Multiple linear regression model estimating associations between excess weight gain and scores on the Dutch Eating Behaviors Questionnaire subscales. Zero-order r Emotional Emotional External Restrained Mean SD

External 0.60

1.94 0.80

Restrained

⁎⁎⁎

p

95% CI

0.33 −0.05 0.10

.015 .708 .413

0.06, 0.54 −0.30, 0.21 −0.12, 0.29

Excess weight gain

⁎⁎

0.31⁎⁎ 0.21⁎ 0.16

0.26 0.33⁎⁎⁎

2.77 0.71

β

2.32 0.82

F (3, 78) = 3.24, p = .027, R2 = 0.11

⁎

p < .05. p < .01. ⁎⁎⁎ p ≤ .001. ⁎⁎

Table 2 Multiple linear regression model estimating associations between excess weight gain and scores on the Food Craving Inventory “Craving Frequency” subscales. Zero-order r High fat foods High fat foods Sweets Carb./starches Fast foods Mean SD ⁎

1.73 0.61

Sweets

Carb./starches ⁎⁎⁎

Fast foods ⁎⁎⁎

0.20

0.51 0.48⁎⁎⁎

0.40 0.44⁎⁎⁎ 0.54⁎⁎⁎

2.51 0.80

2.16 0.71

2.48 0.76

β

p

95% CI

0.51 0.07 −0.36 0.21

< .001 .577 .022 .132

0.20, 0.64 −0.16, 0.29 −0.64, −0.05 −0.05, 0.40

Excess weight gain 0.40⁎⁎⁎ 0.15 0.08 0.23⁎

F (4, 69) = 4.92, p = .001, R2 = 0.22

p < .05. p ≤ .001.

⁎⁎⁎

energy extraction from food (Ma et al., 2014). The finding that cravings for high fat foods had an especially powerful impact on GWG is thus notable. The lack of lasting behavior change in many weight loss interventions for non-pregnant individuals is increasingly attributed to a failure to incorporate techniques to manage food cravings. Food cravings have now also been implicated in excess weight gain in pregnancy (Orloff et al., 2016). Our findings add to this growing body of research and point to proximal antecedents of craving episodes in pregnancy as potentially modifiable predictors of excess GWG. Our data specifically indicate that emotional cues or mood changes may trigger strong urges for high-fat foods in pregnant women. Results thus suggest that cognitive- behavioral interventions targeting food cravings, along with their emotional antecedents, may be useful in promoting healthy weight gain in pregnant women in addition to treatment as usual, which often targets diet and physical activity only. Past studies on acceptance-based strategies for coping with food cravings have shown to be more effective than control-based strategies for samples who are more susceptible to food and food cues (Forman et al., 2007). Future work should examine the utility of these approaches specifically in pregnancy. The fact that food cravings in pregnancy were associated specifically with a tendency to eat in response to emotional cues also highlights the importance of routine screening in the obstetrics setting for mood disorders, which may be another way to help women better manage their weight so as to reduce some of the adverse outcomes associated with excess GWG (Accortt & Wong, 2017). In sum, given their profound and lasting impact, targeting emotional eating and food cravings during pregnancy has the potential to yield long-lasting benefits for both the mother and the infant.

Bain, E., Crane, M., Tieu, J., Han, S., Crowther, C. A., & Middleton, P. (2015). Diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database of Systematic Reviews, 4. Bannon, A. L., Waring, M. E., Leung, K., Masiero, J. V., Stone, J. M., S., E. C., & Moore Simas, T. A. (2017). Comparison of self-reported and measured pre-pregnancy weight: Implications for gestational weight gain counseling. Maternal and Child Health Journal, 21(7), 1469–1478. Bayley, T. M., Dye, L., Jones, S., DeBono, M., & Hill, A. J. (2002a). Food cravings and aversions during pregnancy: Relationship with nausea and vomiting. Appetite, 38, 45–51. Bayley, T. M., Dye, L., Jones, S., DeBono, M., & Hill, A. J. (2002b). Food cravings and aversions during pregnancy: Relationships with nausea and vomiting. Appetite, 38(1), 45–51. Belzer, L. M., Smulian, J. C., Lu, S. E., & Tepper, B. J. (2010). Food cravings and intake of sweet foods in healthy pregnancy and mild gestational diabetes mellitus. A prospective study. Appetite, 55(3), 609–615. Bowen, D. J. (1992). Taste and food preference changes across the course of pregnancy. Appetite, 19, 233–242. Burton, P., Smit, H. J., & Lightowler, H. J. (2007). The influence of restrained and external eating patterns on overeating. Appetite, 49(1), 191–197. Chang, M. W., Nitzke, S., Guilford, E., Adair, C. H., & Hazard, D. L. (2008). Motivators and barriers to healthful eating and physical activity among low-income overweight and obese mothers. Journal of the American Dietetic Association, 108(6), 1023–1028. Crystal, S. R., Bowen, D. J., & Bernstein, I. L. (1999). Morning sickness and salt intake, food cravings, and food aversions. Physiology & Behavior, 67(2), 181–187. Deputy, N. P., Sharma, A. J., & Kim, S. Y. (2015). Gestational weight gain–United States, 2012 and 2013. Morbidity and Mortality Weekly Report, 1215. Fairburn, C. G., Stein, A., & Jones, R. (1992). Eating habits and eating disorders during pregnancy. Psychosomatic Medicine, 54, 665–672. Flaxman, S. M., & Sherman, P. W. (2000). Morning sickness: A mechanism for protecting mother and embryo. The Quarterly Review of Biology, 75(2), 113–148. Forman, E. M., Hofffman, K. L., McGrath, K. B., Herbert, J. D., Brandsma, L. L., & Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45, 2372–2386. Gaillard, R. (2015). Maternal obesity during pregnancy and cardiovascular development and disease in the offspring. Europen Journal of Epidemiology, 30(11), 1141–1152. Galtier-Dereure, F., Boegner, C., & Bringer, J. (2000). Obesity and pregnancy: Complications and cost. American Journal of Clinical Nutrition, 71, 1242S–1248S. Gante, I., Amaral, N., Dores, J., & Almeida, M. C. (2015). Impact of gestational weight gain on obstetric and neonatal outcomes in obese diabetic women. BMC Pregnancy and Childbirth, 15, 249. Goodrich, K., Cregger, M., Wilcox, S., & Liu, J. (2013). A qualitatibe study of factors affecting pregnancy weight gain in African American women. Maternal and Child Health Journal, 17(3), 432–440. Harries, J. M., & Hughes, T. F. (1958). Enumeration of the “cravings” of some pregnant women. British Medical Journal, 2(39), 39–40. Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. (White Paper, accessed at http://

References Accortt, E. E., & Wong, M. S. (2017). It is time for routine screening for perinatal mood and anxiety disorders in obstetrics and gynecology settings. Obstetrical & Gynecological Survey, 72(9), 553–568. ADA (2002). Position of the American Dietetic Association: Nutrition and lifestyle for a healthy pregnancy outcome. Journal of the American Dietetic Association, 102, 1479–1490.

123

Eating Behaviors 31 (2018) 120–124

L.E. Blau et al.

Phelan, S., Phipps, M. G., Abrams, B., Darroch, F., Schaffner, A., & Wing, R. R. (2011). Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: The Fit for Delivery Study. American Journal of Clinical Nutrition, 93, 772–779. Polley, B. A., Wing, R. R., & Sims, C. J. (2002). Randomized controlled trial to prevent excessive weight gain in pregnant women. International Journal of Obesity and Related Metabolic Disorders, 26(11), 1494–1502. Pope, J., Skinner, J. D., & Carruth, B. R. (1992). Cravings and aversions of pregnant adolescents. Journal of the American Dietetic Association, 92, 1479–1482. Rasmussen, K. M., & Yaktine, A. L. (Eds.). (2009). Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academies Press. Sanabria-Martinez, G., Garcia-Hermoso, A., Poyatos-Leon, R., Alvarez-Bueno, C., Sanchez-Lopez, M., & Martinez-Vizcaino, V. (2015). Effectiveness of physical activity interventions on preventing gestational diabetes mellitus and excessive maternal weight gain: A meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 122(9), 1167–1174. Shloim, N., Hetherington, M., Rudolf, M., & Feltbower, R. G. (2015). Relationship between body mass index and women's body image, self-esteem and eating behaviours in pregnancy: A cross-cultural study. Journal of Health Psychology, 20(4), 413–426. Siega-Riz, A. M., Viswanathan, M., Moos, M. K., Deierlein, A., Mumford, S. L., Knaack, J., ... Lohr, K. N. (2009). A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: Birthweight, fetal growth, and postpartum weight retention. American Journal of Obstetrics and Gynecology, 201(4) (339.e331-339.e314). Skinner, J. D., Pope, J. F., & Carruth, B. R. (1998). Alternations in adolescents' sensory taste preferences during and after pregnancy. Journal of Adolescent Health, 22(1), 43–49. Skouteris, H., Hartley-Clark, L., McCabe, M., Milgrom, J., Kent, B., Herring, S. J., & Gale, J. (2010). Preventing excessive gestational weight gain: A systematic review of interventions. Obesity Reviews, 11(11), 757–768. Stamnes Koepp, U. M., Frost Andersen, L., Dahl-Joergensen, K., Stigum, H., Nass, O., & Nystad, W. (2012). Maternal pre-pregnancy body mass index, maternal weight change and offspring birthweight. Acta Obstetrica et Gynecologica Scandinavica, 91(2), 243–249. Stotland, N. E., Hopkins, L. M., & Caughey, A. B. (2004). Gestational weight gain, macrosomia, and risk of cesarean birth in nondiabetic nuliparas. Obstetrics & Gynecology, 104(4), 671–677. Swann, R. A., Von Holle, A., Torgersen, L., Gendall, K., Reichborn-Kjennerud, T., & Bulik, C. M. (2009). Attitudes towards weight gain during pregnancy: Results from the Norwegian mother and child cohort study (MoBa). International Journal of Eating Disorders, 42(5), 394–401. Thorsdottir, I., Torfadottir, J. E., Birgisdottir, B. E., & Geirsson, R. T. (2002). Weight gain in women of normal weight before pregnancy: Complications in pregnancy or delivery and birth outcomes. Obstetrics & Gynecology, 99(5), 799–806. Vahratian, A., Siega-Riz, A. M., Savitz, D. A., & Zhang, J. (2005). Maternal pre-pregnancy overweight and obesity and the risk of cesarean delivery in nulliparous women. Annals of Epidemiology, 15(7), 467–474. Van Strien, T., Frijters, J. E., Bergers, G., & Defares, P. B. (1986). The Dutch Eating Behavior Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. International Journal of Eating Disorders, 5(2), 295–315. Wolfram, T. (2017). Healthy weight during pregnancy. Eat Right. Retrieved from https:// www.eatright.org/health/pregnancy/prenatal-wellness/healthy-weight-duringpregnancy.

www.afhayes.com/public/process2012.pdf on 8/5/2016). Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: The Guilford Press. Hill, B., Skouteris, H., Fuller-Tyszkiewicz, M., & McPhie, S. (2016). Can a health coaching intervention delivered during pregnancy help prevent excessive gestational weight gain? Journal of Behavioral Medicine, 39(5), 793–803. Hilson, J. A., Rasmussen, K. M., & Kjolhede, C. L. (1997). Maternal obesity and breastfeeding success in a rural population of white women. American Journal of Clinical Nutrition, 66, 1371–1378. Hormes, J. M., & Rozin, P. (2010). Does “craving” carve nature at the joints? Absence of a synonym for craving in many languages. Addicive Behaviors, 35(5), 459–463. https:// doi.org/10.1016/j.addbeh.2009.12.031. Kavanagh, D. J., Andrade, J., & May, J. (2005). Imaginary relish and exquisite torture: The Elaborated Intrusion theory of desire. Psychological Review, 112(2), 446–467. Laitinen, J., Jaaskelainen, A., Hartikainen, A. L., Sovio, U., Vaarasmaki, M., Pouta, A., ... Jarvelin, M. R. (2012). Maternal weight gain during the first half of pregnancy and offspring obesity at 16 years: A prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 119(6), 716–723. Liu, J., Wilcox, S., Whitaker, K., Blake, C., & Addy, C. (2015). Preventing excessive weight gain during pregnancy and promoting postpartum weight loss: A pilot lifestyle intervention for overweight and obese African American women. Maternal and Child Health Journal, 19(4), 840–849. Lobel, M., Cannella, D. L., Graham, J. E., DeVincent, C., Schneider, J., & Meyer, B. A. (2008). Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychology, 27(5), 604–615. Ma, J., Prince, A. L., Bader, D., Hu, M., Ganu, R., Baquero, K., ... Aagaard, K. (2014). Highfat maternal diet during pregnancy persistently alters the offspring microbiome in a primate model. Nature Communications, 5, 3889. Mamun, A. A., Kinarivala, M., O'Callaghan, M. J., Williams, G. M., Naiman, J. M., & Callaway, L. K. (2010). Associations of excess weight gain during pregnancy with long-term maternal overweight and obesity: Evidence from 21 y postpartum followup. American Journal of Clinical Nutrition, 91(5), 1336–1341. McGiveron, A., Foster, S., Pearce, J., Taylor, M. A., McMullen, S., & Langley-Evans, S. C. (2015). Limiting antenatal weight gain improves maternal health outcomes in severely obese pregnant women: Findings of a pragmatic evaluation of a midwife-led intervention. Journal of Human Nutrition and Dietetics, 28(1), 29–37. Oken, E., Rifas-Shiman, S. L., Field, A. E., Frazier, A. L., & Gillman, M. W. (2010). Maternal gestational weight gain and offspring weight in adolescence. Obstetrics & Gynecology, 112(5), 999–1006. Oken, E., Taveras, E. M., Kleinman, K. P., Rich-Edwards, J. W., & Gillman, M. W. (2007). Gestational weight gain and child adiposity at age 3 years. American Journal of Obstetrics and Gynecology, 196(4), 322.e321–322.e328. Olson, C. M., Strawderman, M. S., & Reed, R. G. (2004). Efficacy of an intervention to prevent excessive gestational weight gain. American Journal of Obstetrics and Gynecology, 191(2), 530–536. Orloff, N. C., Flammer, A., Hartnett, J., Liquorman, S., Samelson, R., & Hormes, J. M. (2016). Food cravings in pregnancy: Preliminary evidence for a role in excess gestational weight gain. Appetite, 105(1), 259–265. Orloff, N. C., & Hormes, J. M. (2014). Pickles and ice cream! Food cravings in pregnancy: Hypotheses, preliminary evidence, and directions for future research. Frontiers in Psychology, 5(1–15). Paterson, H., Hay-Smith, J., Treharne, G., Herbison, P., & Howarth, C. (2016). Validation of the Intuitive Eating Scale in pregnancy. Journal of Health Psychology, 1–9.

124